ALiEMU CAPSULES Module 5: Procedural Sedation & Analgesia in the ED

We are proud to present CAPSULES module 5: Procedural Sedation & Analgesia in the ED, now published on the Academic Life in EM University (ALiEMU) website. Here is a summary of the key points from this outstanding module by Dr. Zlatan Coralic and Dr. Nadia Awad.

Summary: Procedural Sedation Module

Prior to conducting procedural sedation in the Emergency Department, collection and evaluation of various components related to the medical history of the patient are essential.

The AMPLE mnemonic may be used: Allergies, current Medications, Past medical history, Last meal (solids and liquids), and Event leading to the visit to the ED.

When performing procedural sedation in the ED, monitoring of hemodynamic status is key. Resuscitative equipment and medications, including antidotal agents, should be readily available in the setting of patient decompensation.

Consideration of pharmacological agents in the setting of procedural sedation should account for patient age, comorbid conditions, level of sedation necessary to perform the procedure, and desired duration of sedation.

Ketamine

Ketamine has been widely used for procedural sedation in the ED for in kids and adults due to its multimodal effects in causing sedation, dissociation, and analgesia. It may be administered intravenously or intramuscularly at doses ranging between 1.5 and 2 mg/kg and 4 to 5 mg/kg, respectively.

Non-pharmacological efforts to place patients at ease with the procedural sedation prior to administration of ketamine should be done to minimize the severity of emergence reaction. Should patients experience this phenomenon, titratable doses of benzodiazepines may be administered.

Common concerns associated with the use of ketamine include increased intraocular pressure and increased intracranial pressure, although there has been some published controversy in recent literature regarding the true association of these effects with ketamine.

Prophylactic doses of antiemetics may be considered in pediatric patients who are at high risk of nausea and vomiting with the use of ketamine for procedural sedation, particularly in those patients with higher body mass index and in those receiving ketamine via the IV route.

Although prophylactic anti-sialogogues may be considered in patients receiving ketamine for procedural sedation, routine use of these agents is generally not recommended.

Adverse effects of ketamine include an increase blood pressure, heart rate, and myocardial oxygen demand. Caution should be exercised in patients with coronary artery disease.

Propofol

Propofol has been widely used for adult and pediatric procedural sedation in the ED. Due to its fast onset of action and short duration of action, it is a popular agent for those procedural sedations that require minimal and rapid manipulation.

While propofol possess sedative and amnestic properties, it lacks analgesic effects, and for this reason, concomitant analgesic agents may be necessary, particularly in the setting of painful procedural sedation.

Adverse effects associated with propofol in procedural sedation include hypotension and respiratory depression. These transient effects may be mitigated with the use of longer titration times between administration of propofol bolus doses, basic airway maneuvers and bag-valve mask technique when appropriate, and volume resuscitation prior to and during the procedure.

Ketofol

In recent years, the use of ketofol (combination of ketamine and propofol) has emerged as a popular technique for procedural sedation in the ED. It has some theoretical advantages in maximizing the pharmacokinetic and pharmacodynamic properties of both agents while minimizing the risk of adverse events associated with ketamine and propofol relative to either agent alone.

Various admixture techniques have been evaluated for use in procedural sedation. Regardless of the proportion of agents utilized in this manner, it is essential that providers are aware that additional time may be required for calculation of appropriate doses for administration with proper labeling of syringe(s) and an established sequence of administration is shared with all those involved in the procedural sedation.

Consider avoiding the combination of propofol and ketamine in the same syringe. This can caused confusion since the combination looks like propofol. In addition, the kinetics of ketamine are different than propofol. Generally only one initial dose of ketamine is needed. Then propofol can be titrated and repeated to optimize the sedative effect.

At this time, there is inadequate scientific evidence to suggest that ketofol allows for a predictable duration and length of procedural sedation relative to the use of either agent alone. If ketamine and propofol are used together, monitoring should be considered and conducted similarly as with the use of either agent alone.

Etomidate

Not only does etomidate have a quick onset and short duration of action, but it also minimally affects hemodynamic status, making it an ideal agent for use in procedural sedation in the ED.

Myoclonus associated with etomidate may be of concern, and caution is advised for use in patients with an underlying history of seizures.

Methohexital

Due to its properties as a barbiturate in causing transient apnea and hemodynamic instability, methohexital is not commonly utilized for procedural sedation in the ED, especially with the emergence of relatively newer agents to market.

Dexmedetomidine

There is limited literature currently available related to the use of dexmedetomidine for procedural sedation in the ED, most of which has been evaluated in the pediatric population and non-painful procedures.

Its use may be associated with profound decrease in blood pressure and heart rate, and due to its lack of deep sedative and analgesic properties as well as its complicated dosing scheme and need for continuous infusion, it may be less than ideal for routine use in the ED.

Fentanyl and Midazolam

Fentanyl is routinely administered with a sedative (such as midazolam) in the setting of procedural sedation, with typical doses ranging from 1 to 2 mcg/kg administered IV.

Common concerns associated with administration of fentanyl extend beyond those typically associated with opioid analgesics (respiratory depression and apnea), and includes chest-wall rigidity. This has been associated with the need of emergent intubation and neuromuscular paralysis due to laryngospasm. To prevent this, fentanyl should be administered as a slow IV push over three to five minutes. Subsequent flushing of the IV line following administration should be conducted in a slow and cautious manner.

As a benzodiazepine, midazolam possesses sedative-hypnotic and amnestic properties. For procedural sedation, in addition to monitoring patients for cardiopulmonary compromise, paradoxical excitation may also occur following administration of midazolam. Flumazenil should be readily available at the bedside in the setting where reversal may be necessary for severe cases of this reaction.

What is the CAPSULES series?

The CAPSULES series is a free, online e-curriculum of high-quality, practical, and current information about practical pharmacology for the EM practitioner. Each month a new course module is released, which has lessons to read about (or watch) and brief quizzes to complete. With each step, your personal dashboard will keep track of what you have completed. The CAPSULES series’ primary focus is bringing Emergency Medicine pharmacology education to the bedside. Our expert team distills complex pharmacology principles into easy-to-apply concepts. It’s our version of what-you-need-to-know as an EM practitioner.

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